Immunization Schedule - Expanded Programme, WHO recommendations - Immunization
 
IMMUNIZATION SCHEDULE
Last Updated : 2/15/2016
Sayenna Uduman
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The individual vaccine Highlights
They are as follows:

BCG vaccine
Birth dose used in more than 100 countries to reduce the incidence of disseminated and other life-threatening manifestations of tuberculosis in infants and young children. The various BCG vaccines used throughout the world differ in composition and efficacy. The estimated protection offered was estimated to be 50 to 80% Revaccination is not indicated because of limited effectiveness and potential adverse reactions.
• Have its greatest effect in preventing miliary TB or TB meningitis, so it is still extensively used even in countries where efficacy against pulmonary tuberculosis is negligible.
• Protection afforded was estimated to be 50 – 80% because of variable strain & attenuation of BCG vaccine used. The reported adverse reactions are as low as 1 -2 %.
Infant not vaccinated at birth may require tuberculin skin testing before giving BCG for children age more than 3 months. : In countries with significant number of TB patients in the community, children are vulnerable to get TB infection early in life: Therefore it is recommended (WHO, CDC) to consider tuberculin skin testing after the age of 3 months before BCG vaccination.

Hepatitis B Vaccine (HepB)
3 doses: birth dose, 1-2 Mon and 6 to 18 months of age.
• Administer monovalent HepB vaccine to all newborns before hospital discharge. Monovalent HepB vaccine should be used for doses administered before age 6 weeks
• The second dose is given 1 to 2 months after the first dose (minimum interval of 4 weeks).
• A total of 4 doses of HepB vaccine is permitted when a combination vaccine containing HepB is administered after the birth dose. (UAE immunization schedules).
• The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks.
• For infants born HBsAg-positive mothers, administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) at age 9 through 12 months (preferably at the next well-child visit) or 1 to 2 months after completion of the HepB series if the series was delayed. (see MMWR October 9, 2015;64(39):1118-20)

Polio vaccines
• OPV - birth dose used in many developing countries + routine primary 4 doses <15mon of age
• High scientific evidence show that the OPV schedules starting with a birth dose are at least as immunogenic as otherwise comparable OPV schedules starting at 6-8 weeks of age. (WHO-statement on Quality of Evidence - Jan 24, 2014)...
• ACIP recommends a 4-dose series of all IPV at ages 2, 4, 6 through 18 months, and 4 through 6 years. The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose.
• All IPV or OPV / IPV on sequential orders, may be key for the global polio eradication effort .The IPV substantially boosts both mucosal and serological immunity in children previously vaccinated with OPV & have major operational implications for the global polio eradication effort.
• If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child's current age.
• If only OPV were administered, and all doses were given prior to 4 years of age, one dose of IPV should be given at 4 years or older, at least 4 weeks after the last OPV dose.

Rotavirus – oral (RV)
Two kind of licensed Rota vaccines i.e.RV1, the Rotarix (2-dose series) or RV5- Rota- Tea (3-dose series).
• IAP has revised Rotavirus vaccine to 10 & 14 weeks from existing 6 & 10 weeks of age. Only 2 doses of RV1 (Roterix) are recommended at present.
• Minimum age for immunization is 10 weeks for both RV1 and RV5. ?The maximum age for the first dose in the series is 14 weeks, 6 days; vaccination should not be initiated for infants aged 15 weeks, 0 days or older.
• The maximum age for the final dose in the series is 8 months, 0 days.
• If any dose in the series was unknown, a total of 3 doses of RV vaccine should be administered.

Diphtheria and tetanus toxoids and pertussis (DTP) vaccines
There are 3 vaccine types in the market either whole cell pertussis component (DTwP) or acellular type (DTaP), and the Tdap components (contains tetanus toxoid , reduced adult dose diphtheria toxin and acellular pertussis components )
• Minimum age for immunization is: 6 weeks).
• ACIP recommends a 5-dose series of DTaP vaccine at ages 2, 4, 6, 15 through 18 months, and 4 through 6 years. The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed since the third dose.
• In contrast, the IAP schedules recommends DTwP vaccines for the primary 3 doses with a choice of booster doses are either the DTwP or DTaP component’s .
• It has become clear that the immunity evoked by the DTaP vaccine, which has been in wide use since the late 1990s, is less durable than the immunity evoked by the DTwP.
• From age 11 yrs. onwards every 10 years , the Tdap is recommended
• Administer 1 dose of Tdap vaccine to all adolescents aged 11 through 12 years & repeat every 10 years throughout life.
• Administer one dose of Tdap vaccine to women during each pregnancy (preferred during 27 through 36 weeks gestation) regardless of time since prior Td or Tdap vaccination.
• Maternal Tdap vaccine administration during every pregnancy is to provide Trans placental antibodies, protecting newborn infants by “cocooning” effect. . 'Cocooning' reduces whooping cough risk in Infants.
Pertussis:
• Recent study has shown vaccinating parents of newborn infants against pertussis provides moderate protection against the infectious disease in young infants.
• This targeted vaccination strategy, called cocooning, has been recommended for more than a decade, but its uptake has been limited, absent evidence of its field effectiveness. 'Cocooning' reduces Whooping Cough Risk in Infants
• In adolescents and adults, pertussis can be severe but is rarely life-threatening, as it can be in infants. Since children and adults can expose infants to pertussis, it is important to administer the Tdap vaccine in all persons who could be in contact with an infant; administration of the Tdap vaccine during every pregnancy, to provide transplacental antibodies, has also been recommended.(NEJM , Feb 19, 2015)

Haemophilus influenzae type b (Hib) conjugate vaccines
Minimum age: 6 weeks.
PRP- capsular antigen conjugated with CRM-197 or tetanus toxoid is used as carrier proteins. These carrier proteins are highly immunogenic after completion of three primary doses in infants with a booster at 12 to 18 months. Combination-Vaccine with multiple antigen (tetra, pentad & hexavalent components*) are available.
• Administer a 2 or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4 depending on vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series.
[*Hexavalent vaccine is composed of rHepB + DTap + Hib + IPV; Pentavalent is composed of rHepB +DTwP + Hib and the tetravalent vaccine is composed of DTwP or DTaP+ Hib]

Pneumococcal vaccines
There are two types of conjugated vaccines i.e. 10 &13 valent (PCV 10 & PCV13, the minimum age for vaccination is 6 weeks).
Also, a polysaccharide 23v vaccine (PPSV23) have been in use over 3 decades for high risk children & adults beyond 2 years of age. Polysaccharide vaccines are not protective for children under 2 years of age. Therefore, conjugated pneumococcal vaccines, are developed for universal childhood immunization of infants and children as young as 6 weeks of age. Routine vaccination with PCV10 or 13: a 4-dose series of given at ages 2, 4, and 6 months and at age 12 through 15 months.
• Catch-up vaccination with PCV13: Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely vaccinated for their age.
• Vaccination of persons with high-risk conditions with PCV13 and PPSV23: All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible. For high risk condition, children 2 through 5 years of age consider 2 doses of PCV13 at least 8 weeks apart if unvaccinated or any incomplete schedule of fewer than 3 doses of PCV (PCV7 and/or PCV13) were received previously.
• If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the most recent dose of PPSV23.

Influenza virus vaccines
There are 2 vaccine types 1) Inactivated influenza vaccine (IIV) of trivalent or quadrivalent types. There is no preference and both can be used for annual seasonal immunization with anticipated strains & 2) Live attenuated influenza vaccine (LAIV). (Minimum age: 6 months for IIV and LAIV is administered > 2 years of age)
• The IAP advices influenza vaccines for individuals with high risk medical conditions only.
• ACIP recommends routine IIV vaccination annually to all children beginning at age 6 months and adults including pregnant women.
• Children aged 6 months through 8 years who are receiving influenza vaccine for the first time, receive 2 doses (separated by at least 4 weeks).
• Persons aged 9 years and older receive I dose annually.
• IIV should be administered to all women who will be pregnant during the influenza season, regardless of trimester.
• LAIV should not be given to children with asthma, children 2 to 4 years who had wheezing in the past 12 months and children who have medical conditions that predispose them to influenza complications
• For additional guidance and for the 2016-17 season vaccine await ACIP influenza vaccine recommendations.

Measles, mumps and rubella (MMR) vaccine
A 2-dose series of MMR vaccine given at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose.
• In an area where disease is high, consider, 1 dose of either monovalent measles vaccine (preferred) or MMR vaccine to infants aged 6 through 11 months. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months and the second dose at least 4 weeks later.
• Rubella monovalent vaccine is only given to females in grade 9.

Varicella (VAR) vaccines
Routine administration: Varicella vaccine is given at 12 to 15 months of age. A second dose is currently planned to be given at grade 1 (age 5 to 6 years). The second dose may be given before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid.
For children aged 7 through 12 years, the recommended minimum interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid); for persons aged 13 years and older, the minimum interval between doses is 4 weeks.

Hepatitis A (HepA) vaccine
Minimum age: 12 months.
There are 3 inactivated hepA vaccines in use 1) Havrix (GlaxoSmithKline, US ) , 2) Vaqta (Merck & Co Inc., US) and 3) Avaxim (Sanofi Pasteur, Canada & France). They are available in children & adult formulations.
Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose 6 to 18 months after the first dose
The Indian Academy of Pediatrics, Advisory Committee on Vaccines and Immunization Practices (ACVIP), recommends, single dose live attenuated HepA vaccine (Chinese viral H2 strain) at 12 months of age based on limited published data. Near elimination of the disease was achieved in China for 14 years following introduction of the H2 live vaccine (SC use) into the Expanded Immunization Program (EPI). The CDC and ACIP do not approve this vaccine for childhood immunization practices.
Routine vaccination: Initiate the 2-dose HepA vaccine series at 12 through 23 months; separate the 2 doses by 6 to 18 months.
• Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose 6 to 18 months after the first dose
• For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus infection is desired.

Typhoid Vaccines
There were once three vaccines. Now, there are only two approved and recommended by the ACIP & CDC: These are 1) Ty21a (Vivotif®), an oral, live attenuated vaccine; protection lasts 5 years; minimum age for administration is 6 yrs. and 2) Vi-capsular polysaccharide (VICPS, Typhim Vi®) an IM injection (traveler vaccine); given at age 2 yrs. and above including adult protection lasts 2 years.
IAP recommendation: Considering the epidemiology of typhoid in India, there is definite need of protection against typhoid fever below 2 years of age. Therefore the IAP recommends and included typhoid conjugate vaccine for primary immunization at 9-12 months of age. There are currently two typhoid conjugate vaccines (Typbar-TCV and PedaTyph), licensed in the country. Those who received a dose of conjugate vaccine at 9-12 months can be prescribed booster of either Vi polysaccharide (Vi-PS) or the conjugate vaccine at 2 years of age. Those who have received booster of Vi-PS vaccine will need revaccination every 3 years till the intended duration of protection.

Meningococcal conjugated (MCV4) vaccines
MCV4 is advised for children > 2 yrs. It is not routinely given. Two doses, at least 8 weeks apart, should be given to children 2 to 10 years with complement deficiency or asplenia; 1 dose every 5 years thereafter. Persons with HIV infection who are vaccinated with MCV4 should receive 2 doses at least 8 weeks apart.
Routine vaccination: ACIP recommend a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster dose at age 16 years. IAP recommends for children with high-risk conditions only.

Meningococcal B (MenB vaccines)
MenB vaccine was added to the schedule, indicating vaccination at 10 years of age for people at increased risk. There are two vaccines: Bexsero or Trumenba. Administer a 2 dose series of Bexsero, at least 1 month apart or a 3-dose series of Trumenba, with the second dose at least 2 months after the first and the third dose at least 6 months after the first. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses.
[For complete information on use of meningococcal vaccines, including guidance related to vaccination of persons at increased risk of infection, see MMWR October 23, 2015;64(41):1171-1176 ]

Human Papillomavirus (HPV) Vaccination
Clinical backgrounds: Approximately 40 types of human papillomaviruses (HPVs) infect humans, predominantly through sexual contact. The spectrum of illness ranges from asymptomatic infection to genital warts, genital cancers (particularly cervical cancer), anal and head-and-neck cancers, and rarely, laryngeal papillomatosis (via vertical transmission during vaginal delivery).
Human Papillomavirus (HPV) vaccination schedule Recommendations:
As of this date, there are 3 licensed products available for prevention of HPV infections. These are
1. Bivalent vaccine 2vHPV [Cervarix GSK], covers 16 & 18 serotypes 2.Quadrivalent; 4vHPV [Gardasil], covers 6, 11, 16 & 18 serotypes 3.Recently (2015) approved 9vHPV [Gardasil 9]; 5 additional serotypes 31, 33, 45, 52, and 58
• The 4vHPV vaccine protects against serotypes, which cause 70% of cervical and oropharyngeal cancers.
• Gardasil 9 -v vaccine, recombinant), covers five more HPV types than predecessor Gardasil, both manufactured by MSD. It adds protection against five additional HPV types — 31, 33, 45, 52 and 58 which cause about 20% of cervical cancers and are not covered by previously marketed HPV vaccines.
• Gardasil 9 — approved for females ages 9 through 26 and males ages 9 through 15 — can prevent cervical, vulvar, vaginal and anal cancers caused by HPV types 16, 18, 31, 33, 45, 52 and 58, and genital warts caused by HPV types 6 or 11.

Routine immunization: The vaccine series may be started at age 9 years.
• Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged 11 through 12 years.
• Any of the three vaccines are recommended for females 13 through 26 years of age who have not been immunized or have not completed the series.
• 9vHPV, 4vHPV or 2vHPV may be used for females, and only 9vHPV or 4vHPV may be used for males.
• When administered to adolescents, the HPV-4 vaccine demonstrated durability in clinically effective protection and sustained antibody titers over 8 years, according to a study published in the September 2014 issue of the journal Pediatrics
The IAP, ACVIP schedule recommendations are: two doses of HPV vaccine for adolescent / preadolescent girls aged 9-14 years with the minimum interval between doses should be 6 months. For adolescent girls aged 15 years and older, current 3 dose schedule will continue. However, for immunocompromised individuals, including HIV-infected, the three-dose schedule is recommended, irrespective of age.

Highlights for immunization in special clinical circumstances
• Preterm and LBW infants: Given at the same chronologic age as full term newborn (with some exceptions). Do not split or reduce the dose.
• Personal or family history of seizure: History of seizure is not a contraindication or reason to defer immunization. There is a slight increase in the risk of seizure (in conjunction with fever) after DTwP or MMR-V. The DTaP use has reduced greatly the incidence of seizure.
• High dose systemic corticosteroids (prednisone 2 mg/kg per day, >20 mg/day for >14 days): Delay administering live-attenuated vaccines (LAV) vaccines for 1 month.
• IG or blood products: Delay administering LAV vaccines for variable time intervals.
• Active immunization after exposure to disease: Post-exposure immunization is highly effective and is considered for susceptible persons The most commonly encountered clinical outbreaks are measles, mumps, rubella, pertussis, tetanus, varicella, hepatitis A and B and rabies. Active immunization should be considered with or without simultaneous specific immunoglobulin administration.

Conclusion
Vaccines are among the most effective and safe public health interventions to prevent serious childhood disease and death. Because of the success of vaccines, current younger generations & most public may have no firsthand experience with such devastating illnesses as polio or diphtheria or invasive childhood bacterial diseases like childhood Haemophilus influenza type b diseases or pneumococcal diseases. Widespread immunizations have resulted in a decline in vaccine-preventable diseases. To date, the Institute of Medicine (IOM) of the National Academics committee uncovered no evidence of major safety concerns associated with adherence to the childhood immunization schedule, which should help to reassure parents & public at global level.

References

Contributor Information and Disclosures

Sayenna Uduman
Sayenna A Uduman MD, FAAP
Visiting Professor, Infection Control Committee & ID Division of the KIMS
Thiruvananthapuram, Kerala, India


First Created : 1/9/2001
Last Updated : 1/9/2014

References

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